Eulogio García MDHospital Universitario. “Gregorio Marañón”

Madrid

Eulogio GarcEulogio Garcíía MDa MDHospital Universitario. Hospital Universitario. ““Gregorio MaraGregorio Marañóñónn””

Madrid Madrid

CABG has traditionally been considered the CABG has traditionally been considered the standard treatment for left main PCIstandard treatment for left main PCIPCI with drug eluting stents have reported very PCI with drug eluting stents have reported very promising resultspromising resultsStent thrombosis and bifurcation restenosis Stent thrombosis and bifurcation restenosis were regarded like a threat for good longterm were regarded like a threat for good longterm resultsresultsCareful observation of observational series and Careful observation of observational series and randomized studies will determine the role of randomized studies will determine the role of left main PCIleft main PCI

Duke DatabaseDuke Database

2,24

10,2914,16

18,6822,6

7,72

30 day 1 yr 2 yr 3 yr 4 yr 5 yr

Mor

talit

y R

ate

% N= 1374

CABG for Left Main Disease

Personal communication Peter Berger

1374 1169 1039 902 748 618

Copyleft Clinical Trial Results. You Must Redistribute Slides

CABG surgeryn=1138

Stent implantationn=1102

MAIN-COMPARE Study: Study DesignMAIN-COMPARE Study: Study Design

DES n=784 BMS n=318

2240 patients with unprotected left main artery disease, excludi2240 patients with unprotected left main artery disease, excluding those with prior ng those with prior CABG, valvular & aortic surgery, STEMI, or cardiogenic shockCABG, valvular & aortic surgery, STEMI, or cardiogenic shockProspective. NonProspective. Non--randomized. Observational. randomized. Observational. 49% underwent stent implantation and 51% underwent CABG surgery49% underwent stent implantation and 51% underwent CABG surgery

Primary Endpoint: Death; the composite of death, Q-wave myocardial infarction or stroke; target vessel revascularization (TVR).

1152 days median follow1152 days median follow--upup1017 days median follow1017 days median follow--upup

Presented at SCAI-i2 summit 08

RR

RR

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MAIN-COMPARE Study: SummaryMAIN-COMPARE Study: Summary

The results of this study suggest that there is The results of this study suggest that there is no significant difference in the mortality rate or no significant difference in the mortality rate or the composite risk of death, Qthe composite risk of death, Q--wave MI or stroke wave MI or stroke among patients with unprotected LMCA disease among patients with unprotected LMCA disease who undergo PCI vs. CABG.who undergo PCI vs. CABG.

However, CABG was associated with significant However, CABG was associated with significant reduction in the incidence of target vessel reduction in the incidence of target vessel revascularization compared to PCI.revascularization compared to PCI.

Presented at SCAI-i2 summit 08

HUGM ExperienceHUGM Experience

We have evaluated the results of 101 We have evaluated the results of 101 consecutive patients with left main disease consecutive patients with left main disease treated with percutaneous intervention ( treated with percutaneous intervention ( using Taxus stent ) and follow up for at using Taxus stent ) and follow up for at least 1 yearleast 1 year

TECHNIQUEOstial –Midshaft Lesions

TECHNIQUEOstial –Midshaft Lesions

Simple procedureSimple procedureJL 3.5 6Fr guiding catheterJL 3.5 6Fr guiding catheterConsider wiring form outside ostium and pre Consider wiring form outside ostium and pre IVUS dilatationIVUS dilatationIVUS interrogation of plaque characteristics and IVUS interrogation of plaque characteristics and remodelingremodelingPredilatation or plaque modificationPredilatation or plaque modificationStent implantation and optimizationStent implantation and optimizationIVUS assessment of the resultIVUS assessment of the result

CCM-1

CCM-2

GENERAL STRATEGYGENERAL STRATEGYIVUS interrogation of lesion characteristics helps to IVUS interrogation of lesion characteristics helps to plan the procedureplan the procedureIf stenosis is critical , predilate before IVUSIf stenosis is critical , predilate before IVUSPlaque modification ( cutting ) in cases of calcium or Plaque modification ( cutting ) in cases of calcium or heavy plaque burdenheavy plaque burdenRotational atherectomy if diffuse, calcified diseaseRotational atherectomy if diffuse, calcified diseaseAlways final kissing balloon independent of technique Always final kissing balloon independent of technique usedusedIVUS evaluation of the resultIVUS evaluation of the result

Distal Bifurcation : One or two stents?Distal Bifurcation : One or two stents?

One stent if lesion involves only one vesselOne stent if lesion involves only one vesselOne stent if moderate lesion on branch One stent if moderate lesion on branch vesselvesselTwo stents if severe lesion on bothTwo stents if severe lesion on bothTwo stents if significant lesion and/or Two stents if significant lesion and/or dissection after branch dilatationdissection after branch dilatation

NEED for CARDIOCIRCULATORY SUPPORT NEED for CARDIOCIRCULATORY SUPPORT

When the patient has two of the three When the patient has two of the three following characteristics :following characteristics :

Right coronary artery occludedRight coronary artery occluded

Severe left ventricular disfunctionSevere left ventricular disfunction

Anatomically difficult lesion to treatAnatomically difficult lesion to treat

INCLUSIONS AND EXCLUSIONSINCLUSIONS AND EXCLUSIONS

Patients with significant Patients with significant stenosis of the left main trunk who accepted stenosis of the left main trunk who accepted the percutaneous treatment offered by his the percutaneous treatment offered by his treating physician and the interventional treating physician and the interventional cardiologistcardiologist

patients with AMI in whom patients with AMI in whom the left main was treated during a the left main was treated during a procedure of primary angioplasty procedure of primary angioplasty

Excluded:

Included:

N= 101 . Follow up =25,3 months ( 14.1-44.8 months)

Age 69±11 yrs

Male gender 77

Diabetes 31

Previous MI 25

CD occluded or severily stenosed 58%

Age > 75 yrs 30%

MVD 90%

EF<40% 27%

RISK PROFILE RISK PROFILE

Procedural DataProcedural Data

Stent techniqueStent techniqueOne stent 50 ( 49.5%)

2 stents 51 ( 50.5%)

Final kissing 101 ( 100%)

Procedural Success 100 %Clinical succes 95% Cardiac death 1.7% NQMI 3%Transient CVA 0.6% TVR 0

IN-HOSPITAL RESULTS IN-HOSPITAL RESULTS

Longterm results Longterm results 12

months 25 months

Mortality 6% 6%

MI 3% 3%

TVR 9% 10%

Total MACE 18% 20%

1 mo 12 mo

EF 0.91 (95% CI: 0.86-0.99) 0.76 (95% CI: 0.59-0.98)

Predictors of MortalityPredictors of Mortality

TLR NarrativeTLR Narrative

Mortality Narrative Mortality Narrative

1. 80 yr. CD occluded. EF 30% . Peri procedural MI. Cardiac rupture 5 days post procedure

2. 71 years. CD occluded. EF 15%. 19 days post procedure admitted for CHF. Two days later cardiac arrest post VF. Unsuccessful PCR

3. 75 years EF 35%. Severe aortic stenosis. Severe hypotension. EM disociation

4. 78 years. 7 days post procedure : occlusion LAD ( non treated lesion ) Anterion MI. Shock

5. 83 years old . EF 20%. Sudden death 5 mo. Post-procedure

6. 70 years old. EF 18%. CHF and death 1 month post procedure

CONCLUSIONSCONCLUSIONS

Percutaneous treatment of unprotected left main Percutaneous treatment of unprotected left main disease can be accomplished with safety and disease can be accomplished with safety and efficacy ( good midterm results ) in the era of drug efficacy ( good midterm results ) in the era of drug eluting stents.eluting stents.Polymer based paclitaxel eluting stent ( Taxus) Polymer based paclitaxel eluting stent ( Taxus) used for left main disease is followed by good used for left main disease is followed by good sustained clinical result at long term follow up.sustained clinical result at long term follow up.The technique used was related to lesion type with The technique used was related to lesion type with no difference in outcome observed among no difference in outcome observed among different approaches ( 1 stent only, 1 stent with different approaches ( 1 stent only, 1 stent with final kissing or minicrush ) final kissing or minicrush )